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Occupational Fitness Assessment Form Template

This form should be taken by the injured worker when he or she visits the doctor. The worker needs to fill out and sign the first part so that the doctor knows he or she has the worker’s permission to release important medical information to you. The doctor should fill out the rest of the form and sign it.
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Occupational Fitness Assessment Form Template

General Information

Patient's Name

Doctor's Name

I hereby authorize the release to my employer of all medical information relating to the restrictions that affect my ability to fulfill my regular job duties.

Date

Fitness Assessment Results

Can this employee return to their full duties?

Days/week

Hours/day

Starting Date

Can this employee return to work if identified limitations are accommodated?

Days/week

Hours/day

Starting date

End date

Please indicate which activities he/she will not be able to perform or has limitations.

Bending

Twisting

Squatting/Kneeling

Vision

Hearing

Climbing

Reaching

Lifting/Carrying

Driving

Other (please explain)

In an 8 hour day, the employee may:

Stand (hours):

Walk (hours):

Sit (hours):

Drive (hours):

The employee is capable of:

Sedentary Physical Activities: Lifting less than 5kg mainly seated but occasionally standing or walking about.

Light Physical Activities: Lifting 5-10kg maximum and occasionally lifting and/or carrying such articles as dockets, ledgers, and small tools up to 5kg.

Medium Physical Activities: Lifting 15-25kg maximum with frequent lifting and carrying of objects weighing up to 12kg.

Heavy Physical Activities: Lifting 44kg maximum with frequent lifting and/or carrying of objects weighing up to 22kg.

The employee may use hand(s) for repetitive:

Single Grasping

Pushing and Pulling

Keyboarding

Writing

What type of worksite modification might help in expediting his/her return?

Temporarily________________________ for how long?

Permanently

In cases of stress, please outline in detail the work site stressors and suggested modifications required. Include any environmental or irritant conditions that may need to be addressed. (Please use a separate sheet if additional space is required.)

Recommendations/Comments

Confirmation

I saw this employee on

He/She will be re-evaluated on

Print Name

Phone

Physician’s Signature

Date

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